Exit Life in Recovery Survey - Long Form Adapted from Life in Recovery Survey from Faces and Voices of Recovery 2019 Question Title * 1. What is your gender? Female Male Other Question Title * 2. How old are you? 12-17 18-20 21-35 36-50 51-65 66 and over Question Title * 3. Where do you currently live? Apartment I rent Condominium I rent Home I rent Halfway home or other sober living site Apartment or condominium or home I own With friends With family Currently incarcerated Currently receiving inpatient care Currently homeless Question Title * 4. What is your highest level of education? Some high school or less High school graduate or GED Some college Associate degree Vocational degree or apprenticeship Bachelor’s degree Graduate degree Question Title * 5. What is your current marital status? Now married or living in a partner relationship Divorced, separated, or widowed Never married Question Title * 6. What is your ethnic background? Hispanic or Latino Non Hispanic or Latino Question Title * 7. Which racial background best describes you? American Indian, Native American or Alaska Native Asian Native Hawaiian or other Pacific Islander Black or African American White Hispanic or Latino Other Question Title * 8. Which best describes your current employment status? Employed Full-Time Employed Part-Time Unemployed Student Homemaker Retired Other Question Title * 9. Have you ever served in the US military (active or reserve)? Yes No Question Title * 10. Do you have any children? Yes No Question Title * 11. If you answered Yes to Question #10, how many or your children are under and over the age of 18? Number of children ________under age of 18 Number of children________over age of 18 Question Title * 12. Overall, how would you describe your physical health right now? Poor Fair Good Very Good Excellent Question Title * 13. Are you currently under a doctor’s care for an on-going chronic medical condition (e.g., high blood pressure, diabetes, high cholesterol, asthma, arthritis…)? Yes No Question Title * 14. Overall, how would you currently describe your mental health? Poor Fair Good Very good Excellent Question Title * 15. Are you currently under professional care for a emotional or mental health issue (e.g., trauma, depression, anxiety, thought disorder, ADD…)? Yes No Question Title * 16. Have your ever been treated for a emotional or mental health issue (e.g., trauma, depression, anxiety, thought disorder, ADD…)? Yes No Question Title * 17. Do you use tobacco products (e.g., smoking cigarettes or cigars, snuff)? Yes No Question Title * 18. Have you ever suffered with active addiction issues? Yes No Question Title * 19. If answered yes to Question 18, please complete the following questions about your addiction and recovery Question Title * 20. When you were in active addiction, which substance(s) was your primary problem? Alcohol only Drugs only Both drugs and alcohol Question Title * 21. For how long did you use drugs and/or alcohol in Years (under one year: enter 1) Question Title * 22. When is the last time you drank alcohol or used drugs? (If you do not know the exact day enter ‘15’, if you do know the exact month enter ‘06’) Date Date Question Title * 23. How old were you when you came into recovery? Question Title * 24. Which category best describes how your define yourself now, with respect to you prior alcohol and/or drug use? In Recovery Recovered Used to have an alcohol or drug problem, but don’t any more In medication-assisted recovery Question Title * 25. Thinking of the answer you provided to the previous question, how long have you been in recovery/recovered etc? Less than 1 year Between 1-3 years Between 3-5 years Between 5-10 years Between 10-20 years 20 years or more Question Title * 26. Have you ever gone to a treatment program such as detox, methadone clinic, DUI program, in- or out-patient to deal with drugs and/or alcohol problem? Yes No Question Title * 27. Have you ever taken medications prescribed by a health care professional to deal with drug and/or alcohol problems (e.g., methadone, buprenorphine, Vivitrol – Do Not Include Medications for Mental Health)? Yes No Question Title * 28. If you answered YES to Question 27, otherwise skip to Question 29: Are you currently taking prescription medication to deal with drug and/or alcohol problems to support your recovery? Yes No Question Title * 29. Have you ever attended a 12-step addiction recovery meeting such as Alcoholics or Narcotics Anonymous? Yes No Question Title * 30. If you answered YES to Question 29, otherwise skip to Question 31: Are you currently attending 12-step addiction recovery meetings regularly (once a week or more often)? Yes No Question Title * 31. Have you ever attended a NON 12-step addiction recovery support group (e.g., LifeRing, SMART Recovery/Rational Recovery)? Yes No Question Title * 32. If you answered YES to Question 31, otherwise skip to Question 33: Are you currently attending these NON 12-step addiction recovery support groups regularly (once a week or more often)? Yes No Question Title * 33. Please indicate which of the following events/situations you experienced/engaged in WHILE IN ACTIVE ADDICTION (if NOT APPLICABLE please leave unchecked) Debts/bad credit/bankruptcy/Can’t pay bills Had a bank account Had good credit/restored credit I had my own place to live Owed back taxes Paid back personal debts Paid bills on time Paid taxes/paid back taxes Lost custody of children (other than through divorce) Participated in family activities Planned for the future (e.g., saving for retirement and taking vacations) Regained child custody from protective services or foster care Was a victim or perpetrator of domestic violence Volunteered in community and/or civic group Voted Contracted infectious disease (e.g., Hep C or HIV/AIDS) Exercised regularly Experienced untreated emotional/mental health problems Frequent Emergency Room visits (other than for any ongoing medical/mental conditions) Frequent use of health care services (e.g., hospitals, clinics, doctors) Got regular dental check ups Had a primary care provider Took care of my health (e.g., got regular medical checkups, sought help if needed) Had no health insurance Got arrested Served jail or prison time Damaged property (your own and/or others) DWI Expunged my criminal record Got my driver’s license back Lost right to vote Lost/suspended driver’s license Had no involvement with criminal justice system Got off probation/parole Lost professional or occupational license Restored professional or occupational license Dropped out of school Got fired/suspended at work Frequently missed work or school Furthered my education and/or training Got good job/performance evaluations Started my own business Steadily employed Question Title * 34. Did any other significant event, good or bad, happen to you while in active addiction? (250 characters or less) Question Title * 35. Please indicate which of the following events/situations you experienced/engaged in SINCE YOU CAME INTO RECOVERY. (if NOT APPLICABLE please leave unchecked) Debts/bad credit/bankruptcy/Can’t pay bills Had a bank account Had good credit/restored credit I had my own place to live Owed back taxes Paid back personal debts Paid bills on time Paid taxes/paid back taxes Lost custody of children (other than through divorce) Participated in family activities Planned for the future (e.g., saving for retirement and taking vacations) Regained child custody from protective services or foster care Was a victim or perpetrator of domestic violence Volunteered in community and/or civic group Voted Contracted infectious disease (e.g., Hep C or HIV/AIDS) Exercised regularly Experienced untreated emotional/mental health problems Frequent Emergency Room visits (other than for any ongoing medical/mental conditions) Frequent use of health care services (e.g., hospitals, clinics, doctors) Got regular dental check ups Had a primary care provider Took care of my health (e.g., got regular medical checkups, sought help if needed) Had no health insurance Got arrested Served jail or prison time Damaged property (your own and/or others) DWI Expunged my criminal record Got my driver’s license back Lost right to vote Lost/suspended driver’s license Had no involvement with criminal justice system Got off probation/parole Lost professional or occupational license Restored professional or occupational license Dropped out of school Got fired/suspended at work Frequently missed work or school Furthered my education and/or training Got good job/performance evaluations Started my own business Steadily employed Question Title * 36. Did any other significant event, good or bad, happen to you since you entered recovery? (250 characters or less) Question Title * 37. Overall, how would you rate your quality of life? Poor Fair Good Very good Excellent Question Title * 38. Is there anything you would like to add about the costs of addictions and/or the benefits of recovery to your life? (250 characters or less) Done
